Placenta Previa is a condition in which the placenta attaches itself to the

uterine wall in the lower portion of the uterus and covers all or part of the
cervix. Although the cause of Placenta Previa is unknown, the risk factors
suggest that some cases may be caused by previous scarring of the uterine
wall. These risk factors include: Previous Caesarean Section, Multiparity,
Advanced maternal age, multiple gestation, Erythroblastosis fetalis. The
incidence is approximately 5 per 1,000 pregnancies. It is thought to occur
whenever the placenta is forced to spread to find an adequate exchange
surface. An increase in congenital fetal anomalies may occur if the low
implantation does not allow optimal fetal nutrition or oxygenation.
Placenta Previa occurs in four degrees:

• Low-lying Placenta Previa - in which the placental edge extends within

2 cm of the cervix or is within reach of the examining finger introduced
through the cervix.
• Marginal Placenta Previa - placenta extends to the margin of the
internal cervix opening
• Partial Placenta Previa - placenta partially covers the internal cervical
opening
• Complete Placenta Previa - placenta completely covers internal
cervical opening.

Placenta Previa is much more common in early pregnancy than at term.

During routine second trimester ultrasound, the placenta is observed to cover
the cervix in 5-20% of pregnancies. However, because of the growth of the
uterus throughout the pregnancy, more than 90% of early Placenta Previa's
covert to a normal location by the time of delivery. Conversion to a normal
location is less common in centrally located complete Placenta Previa.

Placenta Previa classically is characterized by painless vaginal bleeding in the

late 2nd or 3rd trimester. However, uterine pain and/or contraction do not
exclude the diagnosis in women with vaginal bleeding. In many cases,
Placenta Previa remains asymptomatic throughout pregnancy.
Historically, Placenta Previa has been associated with increased maternal and
prenatal morbidity and mortality. Preterm delivery and complications of
prematurity are the most common causes of prenatal morbidity, occurring in
nearly 2/3 of cases. Abnormal fetal presentation is observed in up to 30% of
cases. Placental separation and bleeding may cause the newborn to be
anemic. Hemorrhage and complications of Caesarean Section delivery are
the most common causes of maternal morbidity. Blood transfusions are
required in 1/3 to 1/2 of cases.

In addition 9-10% of cases of Placenta Previa are associated with Placenta

Accreta, an abnormally firm attachment of the placenta to the uterine wall.
Placenta Accreta prevents the placenta from separating from the wall of the
uterus at the time of delivery and can cause severe bleeding that often
necessitates a hysterectomy. Placenta Accreta is particularly common in
women with Placenta Previa and one or more previous Caesarean Section's
and may complicate 1/3 to ½ of all such cases. More than 50% of patients
with Placenta Accreta require a blood transfusion.
Many cases of Placenta Previa are diagnosed by ultrasound. In other cases,
the initial diagnosis is made when the patient comes into hospital with
vaginal bleeding during pregnancy. Ultrasound may confirm the suspicion of
Placenta Previa. When the adequate visualization of the relationship between
the placenta and cervix is not possible with abdominal ultrasound, a
transvaginal ultrasound may be helpful. Careful transvaginal sonography
does not appaear to increase the risk of bleeding in Placenta Previa.
Placenta Previa diagnosed by routine second trimester scan is managed
expectantly. The likelihood of spontaneous resolution is greater than 90%.
Strenuous activity may provoke bleeding and should be avoided. Placental
location should be re-evaluated at 28-30 weeks. If Placenta Previa is still
present, the same precautions should be followed. If Placenta Previa persists
beyond 32-34 weeks, resolution by term is uncommon. Caesarean Section is
usually scheduled at a gestational age that will maximize the likelihood of
fetal maturity and minimize the risk of hemorrhage that may result from the
normal onset of uterine contractions. In patients who are not experiencing
bleeding, amniocentesis may be performed at 34-36 weeks to assess fetal
lung maturity. If the baby's lungs are mature, delivery is usually indicated.
Otherwise, management is individualised based on the condition of the
mother and the baby. Waiting beyond 37 weeks is not likely to benefit the
mother or the baby.
The condition of the baby usually is assessed with continuous electronic fetal
heart rate (FHR) monitoring, and ultrasound may be ordered to estimate
gestational age and fetal weight. Medications such as magnesium sulphate,
turbulatine, ritodrine, nifedipine or indomenthacin may be used to stop
uterine contractions.

If the following are present, immediate Caesarean Section is usually

necessary:
Deterioration of the condition of the mother;
Persistent heavy bleeding;
Gestational age >36 weeks;
Estimated fetal weight >2500g;
Fetal distress in a viable fetus;
Contractions that do not respond to medication.

If the initial bleeding episode resolves, the mother and baby remain stable,
and the fetus is premature, it is reasonable to delay delivery. The goal of this
approach is to improve newborn outcome by allowing additional time for the
baby to develop inside the uterus. Bed-rest is usually prescribed, steroids are
given to hasten the development of the baby's lungs if needed.
In women of negative blood type, an injection of Rh immune globulin or
RhoGam is administered. In patients who remain stable for a period of days
after an initial episode of bleeding, the need for continued hospitalisation is
controversial. In selected patients, outplatient management is reasonable
following the first episode of bleeding. If bleeding recurs, prolonged
hospitalization may be necessary. Caesarean Section is the recommended
method of delivery in nearly all cases of Placenta Previa. When possible, the
procedure should be performed electively. Preparations should be made
prior to delivery to ensure adequate venous access and availability of blood
and other necessary medications. If Placenta Accreta is anticipated,
hysterectomy may be necessary and this should be discussed in advance.
Rarely, in the case of low-lying or marginal Placenta Previa the descending
fetal head may 'tamponade' the bleeding placental edge and permit vaginal
delivery. In the past, this possibility was assessed using a "double set-up"
examination in which the patient was taken to the operating room and
prepped for Caesarean Section. A careful examination was undertaken to
determine whether placental tissue could be seen or felt near the cervix, and
the method of delivery determined by the findings. Today, the "double set-
up" examination largely has been replaced by ultrasound evaluation.